There’s so much a person goes through after an injury. From the perspective of the athlete, it could be life changing and career defining experience. One moment you are at the top of your game, the next, you are at the lowest of low. From the acute moment of the injury, to the initial recovery process and through to the final rehabilitation process. It’s a gruelling journey, it’s a fight to get back to the top, a fight not many are even willing to take on, let alone overcome.
I know this because I myself went through it before as a young athlete and now I see it on an almost daily basis the battle my patients face. Allow me to draw upon my own experience here again as an example. After I fractured my tibia (shin bone) for the second time, I put myself through much physiotherapy work to get back to my best. Through the combined efforts of myself and a dedicated team of coaches, I was able to reach previous levels of performances is sports. Well that’s one example, the other isn’t a happy outcome. I had undergone reconstruction surgery for my Anterior Cruciate Ligament (ACL) and this time around I didn’t put in the same amount of effort in physiotherapy. Although I do take part in sports socially now, I have never been able to return to my previous levels of sports, not even close.
These experiences are not unique to me. Lets zoom in our focus here a little towards rehabilitation after ACL surgery. There’s been a lot of attention given to return to sports after an ACL reconstruction surgery. Researches have divided these patients who return to sports into three categories which include: return to any sport, return to pre-injury level and return to competitive level. While about 80% of patients have been reported to return to some degree of sport, only about half of those returned to their pre-injury or competitive level. So, as mentioned above, my case is not unique. In fact I am the rule and not the exception.
So how long does the recovery process take? Or how does one know when they’re ready to start participating in sports again? Before we get into that, let us take a couple of steps back and look at how an ACL reconstruction surgery is done. Essentially, the gist of the surgery is to recreate the ACL which is torn. The surgeon will first create tunnels within the tibia and femur (thigh bone) in the knee. Subsequently, tendons (various forms exist) will be passed through these tunnels and secured to the bone. The biological healing time for this repair takes approximately nine to twelve months. There are three distinctive phases in this healing process, namely the early healing, proliferation and maturation phases.
So now we understand that biological healing plays an important role in the recovery process. This is important because it will be a rate limiting factor in the type or intensity of physiotherapy that the patient or athlete undergoes as well. There are many other factors that could affect the recovery program, for instance, if there was a meniscus or cartilage repair done, in which case the recovery will be slightly slower. In any case, after an ACL reconstruction surgery, the surgeon will prescribe a brace to be worn and crutches to be used to assist with ambulation.
The Rehabilitation process can also be divided into a few phases. There are many rehabilitation protocol that exist, however, most agree that jogging can commence by the 3rd month after surgery followed by training at around 6 months and return to play at sports at around 9 months. In the early stages after surgery, the goal will be to control inflammation and swelling around the knee. Gradually range of motion exercises will begin till full movement is acquired. By the 2nd month strength and proprioception training should be started. These training will be more advance by the 3rd month to include resistance weight training and more sophisticated proprioception training (Proprioception is an important sensing ability which tells the mind what the body’s position is within a certain space).
The 4th month should signal the beginning of running and jumping exercises as well as exercises which are specific to the athletes sporting demands. This progresses up till around the 6th month mark when training for return to sport can begin. These include speed, agility, and specific functional exercises. The full preparation is made by switching from previous simple direction to a more diverse direction with movements of running or jumping in a more power-driven manner. Before return to sport can be recommended after the rehabilitation, the athletes’ involved knee should reach a performance level of at least 85-90% compared to the uninvolved side in test such as strength, balance and functional tests. There are also questionnaires that can guide in judging ones readiness to return to sports.
All of the above plays an undoubtedly important role in rehabilitation but it will not count for much if the athlete is not psychologically ready. From personal experience, I can definitely vouch that this is probably the biggest stumbling block. Where before there was no fear and you would go sliding into a tackle in a football game or you would kick your opponents in a Taekwondo sparing match, there is now doubt. Its always in the back of your mind. To overcome that fear is a huge challenge. Should I go all in? Will I injure my leg again? Luckily for me, after some time, those initial fear eventually went away, although never completely. This part of the recovery is often overlooked, but when you sit down and speak to patients, you see this is a real problem that needs more attention.
Its never a delightful experience getting hurt. Recovery is a long road ahead. For athletes, there is a little extra on the line. Their aim is not merely recovery, but to reach a certain level of performance again. To achieve this, there are many factors that come into play, all of which have to work in harmony to reach that eventual goal.
